- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,786.30 / $7,079.46
| Facility | | $1,445.44 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,047.13 / $2,290.87
| Professional | | $602.56 | $1,047.13 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,388.44 / $11,748.98
| Facility | | $1,258.93 | $3,388.44 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,949.84 / $2,238.72
| Professional | | $1,380.38 | $1,949.84 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,912.51 / $12,589.25
| Facility | | $6,025.60 | $8,912.51 | $12,589.25 |